What Are Some Details on a Patient Chart?

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Quick Answer

According to Health-IT.gov, patient charts consist of health information of patients, such as medical history, vital signs, medications being taken, diagnoses, allergies and test results. Patient charts are used to document individual patients' medical care and history and allow information to be shared between different health care providers.

When a patient is under the care of a health care provider, all past medical information can be found on either an electronic or paper chart. When patients' medical information changes or their condition progresses or improves, it is recorded in their chart. When vital signs, such as blood pressure, heart rate, and temperature, are taken at different intervals of time, this is recorded in a chart. Medications that patients are allergic to are also noted in their chart as to avoid causing an allergic reaction. Test results, including blood tests, are recorded in charts and referred back to when making treatment plans. Information about patients' insurance and where bills should be sent to are also often found in patients' charts.

According to The Free Medical Dictionary, a common method of keeping patients' charts is the "Problem- Oriented Medical Record" or "POMR." POMR focuses mainly on details about the patients that require immediate medical attention, as opposed to the more traditional "diary" method of charting that organizes information by who recorded it. A POMR chart allows for more effective communication between health care professionals.